Analysis Hand-Over Briefings On the ShineiMaruNo.85, an initial hand-over briefing between the pilot and the acting captain would have been difficult because of the language barrier. However, the pilot's instructions to depart from the wharf were relayed to both Japanese officers using the ship's agent as interpreter. At that time, the role of each person on the bridge ought to have been clearly established, but was not. Given that it is the ultimate responsibility of the master to ensure the safe navigation of the vessel at all times, the acting captain ought to have made himself known to the pilot to receive a hand-over briefing and to discuss the pilot's intended passage plan. Those involved made assumptions, and formal hand-over briefings were not carried out. Communication Difficulties While the acting captain possessed a certificate that was STCW endorsed, that certificate was inappropriate to operate a vessel of this size and type. The Japanese officers did not have a working knowledge of English. Because of poor communication and the lack of introductions, the pilot assumed that the fishing master/acting captain was acting solely as the fishing master, and that the radio officer was the captain. The inability to effectively communicate led the pilot to hand over the con of the vessel to an unqualified person. Bridge Operating Practices and Procedures To ensure safe passage in confined waters, a vessel's progress must be closely monitored. Without full knowledge of a vessel's position in relation to the surroundings, the navigational officer's situational awareness is lost. The pilot disembarked the vessel within the limits defined by the pilotage regulations. The exact disembarkation point is left to a pilot's discretion. The Atlantic Pilotage Authority Regulations permit a pilot to embark or disembark a vessel inside the compulsory pilotage waters during heavy weather.4 In this instance, the winds were from the northwest at 15to 20knots and the pilot elected to disembark about 1.5miles inside of the pilot boarding station (see AppendixA). The mate, who was the only person on board with formal navigational training, was not on the bridge because he was engaged in other departure-related activities on deck. Further, the progress of the vessel in pilotage waters and the outer reaches of the harbour was not effectively monitored by ship's personnel. Following the pilot's departure, the acting captain was in his cabin, leaving only the radio officer on the bridge. The mate arrived on the bridge several minutes later and called the captain to the bridge to discuss the seamen's watches. Although there were three officers on the bridge, no dedicated lookout or helmsman was posted, the radar was not monitored, and the progress of the vessel was neither checked against a chart nor were visual references made. No ship-positions were entered in the log book or plotted on the chart. By not having appropriate bridge personnel at their stations during the safety critical phase after the pilot had disembarked, no one was actively engaged in navigating or steering the vessel. Consequently, the officers on the bridge were unaware of the impending danger that resulted in the vessel running aground. Navigation Equipment The type of video plotter on board was used as a fishing aid rather than as a navigational aid. Nevertheless, the vessel's track inbound to Halifax was displayed on the video plotter, and the outbound course to grounding was also visible. The outbound plot line followed the recommended route up until a point just after Lichfield Shoal (when the pilot disembarked). The straight-line plot of the vessel's track then changes direction from Lichfield Shoal to the point of grounding (see Photo3). However, the probable track5 of the vessel is as shown in AppendixA. The gyro compass and the autopilot were functioning satisfactorily, and those involved with navigating the vessel were aware of, and applied, the five-degree autopilot course selection calibration error. There was no information to conclude that following the departure of the pilot, the gyro compass and/or autopilot malfunctioned, that the heading on the auto pilot had been changed, or that the autopilot had been switched to manual. However, the possibility of the autopilot malfunction, autopilot adjustment, or the autopilot being disengaged cannot be discounted. Owing to a wide range of variables, it is not possible to conclude which factor(s) contributed to the change in heading. However, if the bridge personnel had closely monitored the radar display and other navigation equipment, they would have known that the vessel was either falling off or altering course to starboard. It follows that the navigation personnel were inattentive and were not effectively monitoring the vessel's progress. Alcohol Consumption Although it cannot be determined how much alcohol the acting captain consumed before departure, his appearance and behaviour were consistent with someone who had consumed a sizable quantity of alcohol. The degree to which this affected his performance and attitude cannot be determined as blood-alcohol tests were not administered. Marine Communications and Traffic Services Halifax The operator on watch at MCTS Halifax did not notice the ShineiMaruNo.85 veering outside the recommended outbound track, possibly because the radar had dropped the target. This radar glitch happened quite frequently due to ongoing upgrades to the system. However, by the time the pilot disembarks a vessel, it is normally on a safe course towards open seas and requires less attention by operators than traffic in more risk-prone areas. Since the occurrence, MCTS operators have reported improved performance of the radar system. Port State Control Port records indicate that in 2001 there were 109similar vessels (Japanese longliners) that called at the port of Halifax. In2002, there were105, and between January and October in 2003, there were52. In St.John's, Newfoundland and Labrador, there were 30visits in 2001and 41visits in2002. There is no Port State Control inspection requirement on these types of foreign vessels. The need for extending PSC inspections to fishing vessels has been recognized by the International Maritime Organization. The PSCrequirement has been addressed in Article8 of the International Convention on Standards of Training, Certification and Watchkeeping (STCW) for Fishing Vessel Personnel,1995, (STCW-F/95), which has not yet come into force. The convention requires ratification by 15member countries and to date only 4have ratified it. The PSCinspections will provide the opportunity to identify shortcomings, not only with respect to the condition of the vessel but also regarding the adequacy of crew certification. The ShineiMaruNo.85 deviated from its course at the outer reaches of Halifax harbour and grounded for undetermined reasons. No one was monitoring the progress of the vessel after the pilot disembarked, and the deviation in course and its cause went undetected. Safe bridge operating practices and procedures, including basic watchkeeping, were not followed. The officers' inadequate English skills precluded effective communication essential for bridge resource management during pilotage. The pilot disembarked the vessel some 1.5miles inside the pilot boarding station within the compulsory pilotage area.Findings as to Causes and Contributing Factors The ShineiMaruNo.85 deviated from its course at the outer reaches of Halifax harbour and grounded for undetermined reasons. No one was monitoring the progress of the vessel after the pilot disembarked, and the deviation in course and its cause went undetected. Safe bridge operating practices and procedures, including basic watchkeeping, were not followed. The officers' inadequate English skills precluded effective communication essential for bridge resource management during pilotage. The pilot disembarked the vessel some 1.5miles inside the pilot boarding station within the compulsory pilotage area. The acting captain was not properly certificated to have conduct of the ShineiMaruNo.85. The vessel operated at sea for extended periods of time with only one person qualified in navigation. The acting captain had consumed alcohol before the vessel's departure from Halifax. There is no requirement for Port State Control Inspections on fishing vessels, which allows deficiencies in the operation of these vessels to go undetected.Findings as to Risks The acting captain was not properly certificated to have conduct of the ShineiMaruNo.85. The vessel operated at sea for extended periods of time with only one person qualified in navigation. The acting captain had consumed alcohol before the vessel's departure from Halifax. There is no requirement for Port State Control Inspections on fishing vessels, which allows deficiencies in the operation of these vessels to go undetected. Safety Action Action Taken In October2003, the Transportation Safety Board (TSB) issued two Marine Safety Information letters, 10/03and 11/03, to Transport Canada with a copy to the Central Marine Accident Inquiry Agency in Japan advising them of TSB observations regarding the adequacy of certification/vessel crewing and inadequate bridge operating procedures and practices. In response to these concerns, Transport Canada made reference to international initiatives underway that, when fully implemented, have the potential to further safety. Furthermore, Transport Canada will prepare a paper for the IMO STCW Committee identifying the need for flag states that have fishing vessels operating in international waters to ratify the STCW-F/95 convention, or to have their crews certified in accordance with the convention's basic principles. Japan conducted an inquiry into this occurrence and recommended that relevant rules and regulations respecting the qualifications of shipboard personnel be respected by both the vessel operators and staff to help ensure safe operation. Following this occurrence, the Atlantic Pilotage Authority (APA) took measures to formalize best practices in pilotage by more clearly defining the roles of master and pilot in circumstances where the pilot embarks or disembarks at a position other than the pilot boarding station. This would allow a pilot, in bad weather or ice conditions, to board or leave a vessel at a place other than a pilot boarding station. To ensure safety is not compromised, the following procedures are to be followed: The master agrees to embark/disembark a pilot at a location within the compulsory pilotage area. The pilot maintains contact with the master and visually monitors the vessel's progress while the vessel is within the compulsory pilotage waters. These proposed amendments appear in the form of a completely new procedure described in section9.1 of the APARegulations that went into the Canada Gazette Part1 in April2004. The amendments are part of a larger amendment package. As there were objections by some stakeholders, the Minister has appointed an investigator to determine the validity of the objections. The review began the week of 08November2004 and will be considered by the Minister in March/April2005.